Air Precaution in Intensive Care Units

Transcription

1 WFSICCM Seoul 2015 Air Precaution in Intensive Care Units Hye Ran Choi Department of Clinical Nursing University of Ulsan, Republic of Korea

2 Intensive care units Proportion of ICU beds US: 8% South Korea: 6.3% (<General hospital) Prevalence of healthcare-associated infections (HAIs) ICU patients >>> APIC (2014) APIC textbook Statistics Korea (2015)

3 Infection Rate Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) since 1987

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7 Major site infection rate by ward General word in Korea (2006) SSI PNEU BSI UTI GI CVSI SSTI Others Total ICU p-value SSI: surgical site infection PNUE: pneumonia BSI: bloodstream infection UTI: urinary tract infection GI: gastrointestinal system infection CVSI: cardiovascular system infection SSTI: skin and soft tissue infection (%) J. M. Kim et al. (1997) 1996 National nosocomial infection surveillance in Korea

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10 Patients in ICU Extreme age/advanced age Variable invasive procedure Immunocompromised status Implantation of foreign bodies Transplantation Increase of patients with underlying diseases

11 Risk factors for infection/carriage Impaired host defenses Extremes of age Impaired nutritional status

12 Environment of ICU

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17 Isolation Precaution

18 Mode of transmission Contact transmission Direct contact transmission Indirect contact transmission Droplet transmission Airborne transmission

19 ICU patients Major trauma, Respiratory failure and other life-threatening conditions (e.g., myocardial infarction, congestive heart failure, overdoses, strokes, gastrointestinal bleeding, renal failure, hepatic failure, multi-organ system failure, and the extremes of age) Underlying diseases and conditions, Invasive medical devices and technology used in their care (e.g. central venous catheters and other intravascular devices, mechanical ventilators, extracorporeal membrane oxygenation (ECMO), hemodialysis/-filtration, pacemakers, implantable left ventricular assist devices), Frequency of contact with HCP Prolonged length of stay, Prolonged exposure to antimicrobial agents

20 Chain of infection APIC (2015) Guide to hand hygiene programs for infection prevention

21 Droplet transmission >5 μm When? Coughs / Sneezes / Talks Procedures: suctioning, endotracheal intubation, cough induction by chest physiotherapy and cardiopulmonary resuscitation What? Bordetella pertussis, influenza virus, adenovirus, rhinovirus, Mycoplasma pneumoniae, SARSassociated coronavirus (SARS-CoV), group A streptococcus, and Neisseria meningitidis

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23 Airborne transmission 5 μm When? dispersed over long distances by air currents What? spores of Aspergillus spp. Mycobacterium tuberculosis Rubeola virus(measles) Varicella-zoster virus (chickenpox)

24 Transmission from the environment Spores of environmental fungi (eg. Aspergillus spp.) Protective Environment: designed to decrease the risk of exposure to environmental fungal agents in allogeneic hematiopoietic stem cell Transplant (HSCT) patients Environmental sources of respiratory pathogens (eg. Legionella)

25 Cover Your Cough ct/covercough.htm

26 NEJM 2015;372:

27 The index patient a 4-year-old female 3-day history of fever and rash chickenpox encephalitis. Transferred after 12 hours 3 ICU unvaccinated nurses defined after days Nasser Yehia A. Aly et el. Med Princ Pract 2007;16(5):

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29 Shefer A. (2011) Immunization of Health-Care Personnel Recommendations of the Advisory Committee on Immunization Practices (ACIP) Immunization schedules for health-care personnel (HCP) Vaccine Influenza Measles Mumps Rubella Varicella Indication All HCP Vaccination should be recommended for all HCP who lack presumptive evidence of immunity; vaccination should be considered for those born before Vaccination should be recommended for all HCP who lack presumptive evidence of immunity All HCP who do not have evidence of immunity

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31 Negative-pressure room engineering features include negative pressure (greater exhaust than supply air volume); pressure differential of 2.5 Pa (0.01-in. water gauge); air flow volume differential >125-cfm exhaust versus supply; sealed room, approximately 0.5-sq. ft. leakage; clean to dirty air flow; monitoring; >12 air changes per hour (ACH) new or renovation, 6 ACH existing; and exhaust to outside or HEPA-filtered if recirculated.

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33 MERS

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38 June 2015

39 truction-renovation/healthcareprinciples-neg-pressure.htm es/alliedhealth/biomedical/biosafety/t bprevention.html

40 Crit Care Med 2012; 40:

41 Level of disinfection Resistant Level Prions Creutzfeldt-Jakob Disease Prion reprocessing Bacterial spores Bacillus atrophaeus Sterilization Coccidia Cryptosporidium Mycobacteria M. tuberculosis, M. Terrae High Nonlipid or small viruses polio, coxsackie Intermediate Fungi Aspergillus, Candida Vegetative bacteria S. aureus, P. aeruginosa Low Lipid or medium-sized viruses HIV, herpes, hepatitis B Susceptible CDC (2008) Guideline for disinfection and sterilization in healthcare facilities

42 Cleaning of environment AJIC 2013;41:57-60 Enterococcus spp. 62 high-contact site, 17 weeks Pulsed-field gel electrophoresis (PFGE)

43 VSE Surface: 17.2%(352/2,046) Air: 40.9% (27/66) Week 14, VSE Surface: 75/124

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45 Environmental Disinfection UV light Vaporized hydrogen peroxide Others Low-level hydrogen peroxide gas Ozone Formaldehyde Chlorine dioxide 2009 SHEA Lecture slide

46 UV light Vaporized hydrogen peroxide

47 Factors for low compliance of hand hygiene_observed risk Doctor status (rather than a nurse) Nursing assistant status (rather than a nurse) Physiotherapist Technician Male sex Working in intensive/surgical care unit/emergency unit/anaesthiology Working during the week(vs. weekend) Wearing gowns/gloves Before contact with patient environment After contact with patient environment Caring of patients aged less than 65 years old Caring of patients recovering from clean/clean-contaminated surgery in postanaesthesia care unit Interruption in patient-care activities Automated sink Activities with high risk of cross-transmission Understaffing or overcrowding High patient-to-nurse ratio and more shifts per day(hemodialysis unit) High number of opportunities for hand hygiene per hour of patient care WHO Hand hygiene guideline (2009)

48 Factors for low compliance of hand hygiene_self-reported Handwashing agents cause irritations and dryness Sinks are inconveniently located or shortage of sinks Lack of soap, paper towel, handwashing agents Too busy Lack of institutional guidelines/ knowledge/ rewards/ encouragement, role model Not thinking about it Disagreement with recommendations

49 What to need? Routine monitoring and surveillance of infection Compliance of infection prevention procedure (hand hygiene, etc.) Patient placement Personal protective equipment Cleaning, disinfection, and sterilization of environment and equipment Inspection of ICU structure such as ventilation system or negative-air-pressure room Institutional culture

50 Thank you for your attention